The Obstetrician & Gynaecologist | 2019
Authors’ reply
Abstract
Dear Editor We thankBryant-Smith andHolland for their very thorough review article pertaining to alternatives, techniques and controversies surrounding laparoscopic myomectomy. We would like to share our experience of an unusual case of recurrent spontaneous prelabour uterine fundal rupture that occurred following laparoscopic myomectomy. Our patient had recurrent extreme preterm (26 weeks) uterine rupture following laparoscopic myomectomy, despite close monitoring and tocolysis in the second pregnancy. Thus, while the laparoscopic approach is associated with lower blood loss, less pain and more rapid recovery, with similar fertility rates compared with open myomectomy, many authors question the reliability of the hysterotomy repair following laparoscopic myomectomy. Based on a systematic review of pooled data (2017 laparoscopic and 705 open myomectomies), uterine rupture in pregnancy is approximately three times more common following the former approach (1.2% versus 0.4%), although this difference did not reach statistical significance and the overall risk of rupture appears low (<1% of ongoing pregnancies). The strength of the scar tissue is dependent on the depth of the incision, whether or not the uterine cavity is breached, the surgeon’s skills in laparoscopic suturing and postoperative complications such as concurrent haematoma and infection. Excessive use of electrocautery for haemostasis, inadequate laparoscopic closure of the myometrium and a short interval between myomectomy and subsequent conception are other risk factors which can predispose to uterine rupture, and it is crucial that the patient receives careful counselling. Our second point relates to myoma retrieval and the use of laparoscopic morcellators, which can cause inadvertent dissemination of both benign and occult malignant tissue leading to parasitic myomatosis and potential up-staging of leiomyosarcomata. We feel that clinicians often neglect the posterior colpotomy approach (with or without ‘cold knife’ morcellation through the vagina), a natural orifice route that enables complete removal of the specimen and obviates the aforementioned complications.